Impact of anthropometric measures and serum leptin on severity of gastroesophageal reflux disease

The aim of this prospective study was to evaluate the impact of obesity, determined by different anthropometric measures, on clinical and endoscopic severity of GERD and the relation between serum leptin and clinical and endoscopic severity of GERD in Egyptian patients. The study was carried out at Ain Shams University Hospitals and Theodor Bilharz Research Institute, Cairo, Egypt. A total of 60 patients with clinically and endoscopically evident gastroesophageal reflux disease (GERD) were enrolled in this study as well as 20 healthy subjects matched for age and gender serving as the control group. Patients were divided according to their body mass index (BMI) into two groups: group 1 (n = 30): overweight and obese (BMI ≥25 and/or waist‐to‐height ratio [WHtR] ≥0.5) and group 2 (n = 30): normal weight (BMI ≥18 to <25 and/or WHtR ≥0.4 to <0.5). Upper gastrointestinal endoscopy, anthropometric measures, and symptom severity score questionnaire were done for all patients. Serum leptin hormone was assessed for patients and control groups.The evidence revealed statistically significant difference between the two groups in terms of different anthropometric measures (P < 0.00) except the height (P < 0.9), abdominal fat depot equations (P < 0.00), endoscopic findings according to Los Angeles classification (P < 0.001), symptom severity score (P < 0.00), and serum leptin hormone (43.96 ± 23.50 in group 1 vs. 7.5133 ± 8.18294 in group 2 and 6.98 ± 5.90 in the control group) (P = 0.00). Obesity in general and central (abdominal) obesity specifically has significant impact on clinical and endoscopic severity of GERD. Increased leptin hormone level is associated with clinical and endoscopic severity of GERD. Future trial on larger number of patients is emphasized.     

Predictive Factors for Pure Steatosis in Alcoholic Patients

Background: Bearing in mind the mechanisms involved in nonalcoholic fatty liver disease, this study aims to verify whether metabolic syndrome or its various individual components are independent predictive factors for steatosis ≥10% in alcoholic patients. Methods: This study included 281 consecutive alcoholic patients with abnormal liver tests and either normal liver histology or steatosis <10% (n = 119) or steatosis ≥10% (n = 162). Logistic regression analysis was used to study the relationship between metabolic syndrome components and various risk factors and the presence of steatosis ≥10%. We assessed apolipoprotein A1 (ApoA‐1) levels, a major protein component of plasma high‐density lipoprotein (HDL), rather than HDL‐cholesterol levels. Results: Plasma ApoA‐1 levels (p < 0.01), body mass index (BMI) (p < 0.01), and waist circumference (p < 0.05) were significantly higher in patients with steatosis ≥10% than in patients with normal liver histology or steatosis <10%. A higher percentage of patients with steatosis ≥10% had high blood pressure (p = 0.003) than patients with normal liver histology or steatosis <10%. In the logistic regression, ApoA‐1 [odds ratio (OR) = 1.57 (1.10–2.22)], BMI [OR = 1.10 (1.01–1.23)], and high blood pressure [OR = 1.84 (1.10–3.06)] were positively and independently correlated with the presence of steatosis ≥10%. In the multivariate regression high blood pressure was independently and positively correlated with steatosis score (r = 0.55 ± 0.26; p < 0.05). On the other hand, when the presence of high blood pressure was the dependent variable, the presence of steatosis ≥10% positively and independently correlated with it [OR = 1.82 (1.05–3.15)]. Conclusion: In alcoholic patients without fibrosis, ApoA‐1, BMI, and high blood pressure on the next morning after the admission were predictive of steatosis ≥10%. High blood pressure was the only metabolic syndrome component associated with the presence of alcoholic steatosis ≥10% and was not correlated with other metabolic syndrome components. These findings suggest that steatosis mechanisms are different in alcoholic and nonalcoholic fatty liver.     

Creatine Kinase as Predictor of Blood Pressure and Hypertension. Is It All About Body Mass Index? A Follow‐Up Study of 250 Patients

The correlation between creatine kinase (CK) and blood pressure (BP) was examined prospectively in 120 patients with persistent high CK and 130 individuals with normal CK. Hypertension was defined as systolic BP (SBP) ≥140 mm Hg or diastolic BP (DBP) ≥90 mm Hg or current use of antihypertensive medication. Baseline CK was weakly correlated with SBP (r=0.11, P=.07) and DBP (r=0.16, P=.01) at follow‐up. Persons with persistent high CK had higher SBP (140.8 mm Hg vs 138.2 mm Hg) and DBP (83.2 mm Hg vs 81.0 mm Hg, P=.06) values and were more likely to have hypertension (66.7% vs 55.5%, P=.05) than individuals with normal CK. In age‐ and sex‐adjusted analysis, a 1‐unit change in logCK was associated with a 4.9‐mm Hg higher SBP, a 3.3‐mm Hg higher DBP, and a 2.2‐higher odds for having hypertension at follow‐up (P=.1, .07, and .06, respectively). When including body mass index (BMI) to the model, BMI was a strong and independent predictor for SBP, DBP, and hypertension at follow‐up and the CK effect on blood pressure was substantially attenuated. This study showed that the CK effect on blood pressure is clearly modified by BMI.     

Lack of differential pattern in central adiposity and metabolic syndrome in Barrett's esophagus and gastroesophageal reflux disease

Obesity is an established risk factor for esophageal adenocarcinoma, although the mechanism is unclear. A pathway from reflux to inflammation through metaplasia is the dominant hypothesis, and an added role relating to visceral adiposity and the metabolic syndrome has been mooted in Barrett's esophagus (BE) patients. Whether BE differs from gastroesophageal reflux disease (GERD) in obesity and metabolic syndrome profiles is unclear, and this was the focus of this study. Patients with proven BE or GERD were randomly selected from the unit data registry and invited to attend for metabolic syndrome screening, anthropometry studies including segmental body composition analysis, and laboratory tests including fasting lipids, insulin, and C‐reactive protein. Metabolic syndrome was defined using the National Cholesterol Education Program (NCEP) and the International Diabetes Federation (IDF) criteria. One hundred and eighteen BE patients and 113 age‐ and sex‐matched GERD controls were studied. The incidence of obesity (body mass index >30 kg/m²) was 36% and 38%, respectively, with the pattern of fat deposition predominantly central and an estimated trunk fat mass of 13 and 14 kg, respectively. Using the NCEP criteria, metabolic syndrome was significantly more common in the BE cohort (30% vs 20%, P < 0.05), but there was no significant difference using IDF criteria (42% vs 37%, P= 0.340). Central obesity and the metabolic syndrome are common in both Barrett's and GERD cohorts, but not significantly different, suggesting that central obesity and the metabolic syndrome does not per se impact on the development of BE in a reflux population. In BE, the importance of obesity and the metabolic syndrome in disease progression merits further study.     

PREVIEW (Prevention of Diabetes Through Lifestyle Intervention and Population Studies in Europe and Around the World) study in children aged 10 to 17 years: Design,methods and baseline results

Insulin resistance (IR) in adolescence is associated with type 2 diabetes mellitus [T2DM]. The PREVIEW (Prevention of Diabetes Through Lifestyle Intervention and Population Studies in Europe and Around the World) study assessed the effectiveness of a high‐protein, low‐glycaemic‐index diet and a moderate‐protein, moderate‐glycaemic‐index diet to decrease IR in insulin‐resistant children who were overweight or obese. Inclusion criteria were age 10 to 17 years, homeostatic model assessment of IR (HOMA‐IR) ≥2.0 and overweight/obesity. In 126 children (mean ± SD age 13.6 ± 2.2 years, body mass index [BMI] z‐score 3.04 ± 0.66, HOMA‐IR 3.48 ± 2.28) anthropometrics, fat mass percentage (FM%), metabolic characteristics, physical activity, food intake and sleep were measured. Baseline characteristics did not differ between the groups. IR was higher in pubertal children with morbid obesity than in prepubertal children with morbid obesity (5.41 ± 1.86 vs 3.23 ± 1.86; P = .007) and prepubertal and pubertal children with overweight/obesity (vs 3.61 ± 1.60, P = .004, and vs 3.40 ± 1.50, P < .001, respectively). IR was associated with sex, Tanner stage, BMI z‐score and FM%. Fasting glucose concentrations were negatively associated with Baecke sport score (r = ?0.223, P = .025) and positively with daytime sleepiness (r = 0.280, P = .016) independent of sex, Tanner stage, BMI z‐score and FM%. In conclusion, IR was most severe in pubertal children with morbid obesity. The associations between fasting glucose concentration and Baecke sport score and sleepiness suggest these might be possible targets for diabetes prevention.     

Blood Pressure Variability and Left Ventricular Mass Index in Children

Clinical implications of blood pressure variability (BPV) on subclinical organ damage in children are unknown. The authors sought to explore the potential utility of two newly derived BPV indices: weighted standard deviation (wBPSD) and real average variability (ARV), as well as two standard ambulatory blood pressure indices: average 24‐hour systolic blood pressure (SBP) and 24‐hour SBP load, to identify children at high risk for left ventricular (LV) hypertrophy (LVH). The study group consisted of 67 consecutive children who were referred to our institution for evaluation of suspected hypertension. LV mass was estimated by M‐mode echocardiography using Devereux's formula according to the Penn convention and indexed for height^2.7. We found a statistically significant, positive correlation between 24‐hour wBPSD and LV mass index (LVMI) (ρ=0.389; P=.002) and no correlation between 24‐hour ARV and LVMI (P>.05). However, partial correlation analysis of 24‐hour wBPSD adjusted for body mass index (BMI) and LVMI showed only a weak correlation (ρ=0.3; P=.022). By using multiple linear regression analysis in a model with LVMI as a dependent variable and 24‐hour wBPSD, 24‐hour ARV, and BMI as independent variables, only BMI showed statistically significant independent positive associations with LVMI (P=.028). Results of our study showed that currently used BPV indices (24‐hour wBPSD and 24‐hour ARV) are not clinically reliable parameters to identify children at risk for LVH. Apparent contribution of the 24‐hour wBPSD parameter to LVMI is negligible and is secondary to its close correlation with BMI (ρ=0.335 P=.009).     

Nonalcoholic Fatty Liver Disease Increases Risk for Gastroesophageal Reflux Symptoms

Background

Nonalcoholic fatty liver disease (NAFLD) is now recognized as a leading cause of liver dysfunction. Gastroesophageal reflux disease (GERD) is a common disorder causing symptoms that often impair patients’ quality of life. In recent years, the prevalence of both these diseases has increased, partially overlapping the rise of metabolic disorders.

Aims

We investigated whether a relation does exist between NAFLD and GERD symptoms.

Methods

Cross-sectional study among 206 outpatients diagnosed with NAFLD and 183 controls. We collected clinical and laboratory data, assessed severity and frequency of GERD symptoms and the esophageal endoscopic pattern.

Results

The prevalence of GERD symptoms was higher in NAFLD patients than controls (61.2 vs. 27.9 %, p < 0.001). We found a positive association between NAFLD and the experiencing of heartburn, regurgitation and belching. GERD symptoms were related to body mass index (BMI) and metabolic syndrome (MetS); a strong association persisted after adjustment for all the covariates (adjusted OR 3.49, 95 CI % 2.24–5.44, p < 0.001).

Conclusions

Our data show that the prevalence of GERD typical symptoms is higher in patients with NAFLD. GERD was associated with higher BMI and MetS, but not with age and diabetes type 2. NAFLD remained strongly associated with GERD, independently of a coexisting MetS status. Consistent with these findings, MetS can be considered a shared background, but cannot completely explain this correlation. We suggest NAFLD as an independent risk factor for GERD symptoms.     

Diagnostic value of dilated intercellular space and histopathologic scores in gastroesophageal reflux disease

The aim of this paper is to investigate the diagnostic value of histopathologic score and the dilated intercellular space (DIS) in patients with gastroesophageal reflux disease (GERD) and functional heartburn (FH). Participants with GERD symptoms including reflux esophagitis, non‐erosive reflux disease (NERD), Barrett's esophagus (BE), functional heartburn (FH), along with a control group with atypical GERD‐like symptom (Sym‐C), and asymptomatic healthy volunteers (H‐C) were administered GERD questionnaire, and subjected to endoscopy and biopsies, as well as 24‐hour pH‐impedance monitoring. Biopsies were evaluated using standards from the 2011 Esohisto Project after Hematoxylin‐Eosin staining. DIS was measured quantitatively under light microscopy. Among the total of 565 participants with qualified biopsy specimens, the mean DIS of the reflux esophagitis (RE) group was significantly wider compared with the other five groups. DIS in patients with GERD‐like symptoms was significantly wider compared with the H‐C. No significant differences were observed between NERD and FH. Results from 24‐hour pH‐impedance monitoring indicated that only the DIS of patients with acid reflux or the amount of acid reflux episodes in patients with DIS was significantly wider compared with patients with nonacid reflux or patients without DIS (P < 0.001). With DIS = 0.9 μm as the cutoff value, the sensitivity and specificity were 62.6% and 54.1%, respectively. Using the total histopathologic score > 3 as the diagnostic criterion, the sensitivity and specificity were 71.7% and 47.4%. DIS is closely associated with GERD and acid reflux. The diagnostic value of histological scores in lower esophagus in GERD is very similar to that of the quantitative measurement of DIS.     

Metabolic disorders associated with chronic hepatitis C: impact of genotype and ethnicity

Background & aim: Patients with hepatitis C virus (HCV) infection, especially those with genotypes 1 and 4, have an increased risk of developing metabolic disorders. The aim of this study was to evaluate the associations among metabolic disorders, ethnicity and genotype in a large cohort of patients with chronic hepatitis C (CHC). Patients and Methods: All consecutive patients with CHC who were seen in our hepato‐gastroenterology unit between January 2002 and September 2008 were included. Demographical data and variables related to the metabolic syndrome were collected. Insulin resistance was assessed using the homeostasis model for the assessment of insulin resistance test (HOMA‐IR) test. Results: Among the 454 CHC patients, the prevalence of the metabolic syndrome was 12.4%. The HOMA‐IR test was performed in 140 patients, and 35.0% had insulin resistance. There were more Black Africans among the patients with genotypes 1/4 than among those with genotypes 2/3 (32.0 vs 1.2%, P<0.0001). Insulin resistance was more common in patients with genotypes 1/4 than in those with genotypes 2/3 (17 vs 1.7%, P=0.0001 and 43.3 vs 16.3%, P=0.001, respectively). Genotypes 1/4 were more frequently present in patients with insulin resistance than in those without insulin resistance (85.7 vs 60.5%, P=0.001). By logistic regression, genotypes 1/4 [odds ratio (OR)=2.79; 95% confidence interval (CI): 1.09–7.12, P=0.032] and older age (OR=1.03; 95% CI: 1.004–1.06, P=0.024) were independently associated with the presence of insulin resistance. Conclusions: In CHC, insulin resistance is independently associated with the presence of genotypes 1/4. Ethnicity is not independently associated with metabolic disorders in patients with CHC.     

Twice‐daily proton pump inhibitor therapy does not decrease the frequency of reflux episodes during nocturnal recumbency in patients with refractory GERD: analysis of 200 patients using multichannel intraluminal impedance–pH testing

Over half of patients with gastroesophageal reflux disease (GERD) report nocturnal symptoms. Proton pump inhibitors (PPIs) are the main medications used to treat GERD. Multichannel intraluminal impedance with pH (MII‐pH) monitoring is the most sensitive method for detection and characterization of GERD. The aim of this study was to assess and compare reflux frequency in patients with refractory GERD symptoms on and off PPI therapy during the nocturnal recumbent period, as assessed by MII‐pH testing. We analyzed 24‐hour MII‐pH studies performed in 200 patients monitored either on twice‐daily (n = 100) or off (n = 100) PPI therapy. Demographic analysis of the on‐therapy group revealed a mean age of 52 years (24–78 years) with 37% males, and the off‐therapy group revealed a mean age of 49 years (18–84 years) with 40% males. All studies were interpreted to assess and characterize the number of acid and nonacid reflux episodes in the nocturnal recumbent period identified by each patient on an overnight recorder (Zephyr, Sandhill Scientific, Inc., Highlands Ranch, CO, USA). The nocturnal recumbent period was the period documented by patients during which they lie in the recumbent period at night to sleep with average periods lasting 456 and 453 minutes for patients on and off PPI therapy. There were more mean recumbent reflux episodes in the on‐therapy group in comparison with the off‐therapy group (3.76 mean reflux episodes [mre] per patient in the recumbent vs. 2.82 mre); the difference was not statistically significant (P = 0.187). When the reflux events are classified into acid and non‐acid reflux episodes, the relative occurrence of acid reflux events is less in the on‐therapy group (P = 0.047), while the off‐therapy group have fewer nonacid reflux episodes (P = 0.003). PPIs decrease the acidity of esophageal refluxate but do not decrease the relative frequency of reflux episodes in the recumbent position in patients with refractory GERD despite twice‐a‐day treatment with PPI therapy. The explanation for the finding of numerically increased, although not statistically significant, amount of reflux episodes in the PPI treatment group in this study, and previous studies is unclear and warrants further evaluation.     

Effect of acid‐suppressive therapy on narrow band imaging findings in gastroesophageal reflux disease: a pilot study

Standard endoscopy is an insensitive test for gastroesophageal reflux disease (GERD). Narrow band imaging (NBI) endoscopy enhances visualization of the distal esophagus. NBI patterns like intrapapillary capillary loop (IPCL) dilatation, tortuosity, and increased number; microerosions; increased vascularity at the squamocolumnar junction (SCJ); ridge‐villous pattern below the SCJ; and presence of columnar islands in the distal esophagus have been suggested as features of GERD. We evaluated the effect of proton pump inhibitor (PPI) therapy on NBI findings in GERD patients. Patients prospectively underwent NBI upper endoscopy before and after PPI therapy. NBI findings were recorded at each endoscopy. Twenty‐one patients with GERD symptoms (mean age 60.0 years; males 90.5%; white 90.5%) were studied. After PPI therapy, there was a significant reduction in the proportion of patients with the following NBI features: IPCL tortuosity (90% vs. 4.8%, P < 0.0001), dilated IPCLs (86% vs. 9.5%, P < 0.0001), and increased vascularity at the SCJ (43% vs. 9.5%, P= 0.0082). PPI led to healing of all microerosions (71% vs. 0%, P < 0.0001) and disappearance of ridge‐villous patterns below the SCJ (14% vs. 0%, P < 0.0001). There was no significant change in the proportion of patients with increased numbers of IPCLs pre‐ and post‐PPI therapy (71% vs. 48%, P= 0.09) or columnar islands in the distal esophagus (38% vs. 29%, P= 0.31). In patients with GERD symptoms, NBI features suggestive of GERD respond to PPI; suggesting these features are truly acid‐mediated. These findings need to be confirmed by randomized controlled trials.     

Favorable Glucose Tolerance and Lower Prevalence of Metabolic Syndrome in Offspring without Diabetes Mellitus of Nonagenarian Siblings: The Leiden Longevity Study

OBJECTIVES: To explore measures of metabolic syndrome and glucose metabolism in families with exceptional longevity. DESIGN: Case–control study. SETTING: A university hospital in Leiden, the Netherlands. PARTICIPANTS: One hundred twenty‐one offspring of nonagenarian siblings, who were enriched for familial factors promoting longevity, and 113 of their partners. No subject had diabetes mellitus. MEASUREMENTS: Prevalence of metabolic syndrome was determined according to the criteria of the Third Report of the National Cholesterol Education Program. Glucose tolerance was assessed according to a 2‐hour oral glucose tolerance test. RESULTS: The offspring of nonagenarians siblings had a lower prevalence of metabolic syndrome (P=.03), similar body composition, lower mean fasting blood glucose levels (4.99 vs 5.16 mmol/L; P=.01), lower mean fasting insulin levels (5.81 vs 6.75 mU/L; P=.04), a higher mean homeostasis model assessment of insulin sensitivity (0.78 vs 0.65; P=.02), and a more‐favorable glucose tolerance (mean area under the receiver operating characteristic curve for glucose (13.2 vs 14.3; P=.007) than their partners. No significant differences were observed between the offspring and their partners in β‐cell function (insulogenic index 13.6 vs 12.5; P=.38). CONCLUSION: Despite similar body composition, the offspring of nonagenarian siblings showed a lower prevalence of metabolic syndrome and better glucose tolerance than their partners, centralizing the role of favorable glucose metabolism in familial longevity.     

Endothelial Nitric Oxide Synthase Polymorphisms Associated with Abnormal Nitric Oxide Production Are Not Over‐represented in Children with Down Syndrome

Objective. Down syndrome patients are at increased risk for developing pulmonary hypertension (PHTN). Nitric oxide (NO) is an important factor for pulmonary vasoreactivity. Various endothelial nitric oxide synthase (eNOS) polymorphisms have been shown to affect NO. The goal of this study was to determine whether there was a difference in prevalence of eNOS polymorphisms between Down syndrome patients vs. non‐Down syndrome patients. Methods. Down syndrome patients were recruited as well as non‐Down syndrome patients. Gene polymorphisms for eNOS‐3 (GG, GT, TT), eNOS‐4 (bb, ba, aa), and eNOS‐P (TT, TC, CC) were determined. Three forms of the 3 genes were compared in cross‐tabulation tables with Down syndrome patients vs. non‐Down syndrome patients and Down syndrome patients with heart defects vs. those without defects. Association was tested with chi‐square and significance was set at P ≤ .05. Results. Fifty‐one Down syndrome patients and 411 controls were studied. Twenty‐one Down syndrome patients had heart defects and 6 of these patients had documented PHTN. There was no difference in gender between Down syndrome patients (males 56.9%) and controls (males 50.4%), P = .38. Prevalence of eNOS polymorphisms between Down syndrome patients and controls was not different for the genes (eNOS‐3, P = .94; eNOS‐4, P = .40; eNOS‐P, P = .18). There was no difference in gene polymorphisms between Down syndrome patients with heart defects vs. those without defects (eNOS‐3, P = .19; eNOS‐4, P = .29; eNOS‐P, P = .99). Conclusion. Prevalence of various eNOS polymorphisms between Down syndrome patients and controls was not different. Other polymorphisms that are associated with PHTN should be studied to determine whether they may be the cause of the increased risk of PHTN in Down syndrome patients.     

Change of insulin sensitivity in hepatitis C patients with normal insulin sensitivity; a 5‐year prospective follow‐up study variation of insulin sensitivity in HCV patients

Background: Hepatitis C virus (HCV) infection is associated with a high prevalence of diabetes mellitus (DM). Insulin resistance (IR) is known to play a crucial role in the development of DM in chronic hepatitis C (CHC) patients. We prospectively investigated changes of insulin sensitivity in CHC patients during a 5‐year period and analysed the factors significantly associated with IR. Methods: Sixty‐two CHC patients with normal insulin sensitivity (CHC group), and a healthy control group of 172 subjects matched by age, gender, body mass index and lifestyles were studied. We compared the initial baseline insulin sensitivity, metabolic parameters and incidence of IR at the end of the follow‐up period between the two groups. The changes in insulin sensitivity, metabolic parameters and the development of IR were analysed as well as factors associated with the development of IR. Results: IR developed in 22.5% of 62 CHC patients and 5.2% of 172 normal individuals (P < 0.001). HCV infection per se and the genotype 1 were independent risk factors for the development of IR. The duration of infection ≥120 months, initial fasting glucose 90–100 mg/dL, fasting insulin ≥10 µIU/mL and the homeostasis model assessment (HOMA‐IR) 2.3–2.7 were significantly associated with the development of IR in the CHC group. Conclusion: HCV infection was an independent risk factor for the development of IR. All CHC patients, even those with normal insulin sensitivity, require careful monitoring for the development of IR.     

Effects of liraglutide on cardiovascular risk factors in patients with type 1 diabetes

We investigated the short‐term effect of adding liraglutide 1.8 mg once daily to insulin treatment on cardiovascular risk factors in patients with type 1 diabetes. In total, 100 overweight (BMI ≥25 kg/m²) adult patients (age ≥18 years) with type 1 diabetes and HbA1c ≥ 8% (64 mmol/mol) were randomized to liraglutide 1.8 mg or placebo added to insulin treatment in a 24‐week double‐blinded, placebo‐controlled trial. At baseline and after 24 weeks of treatment, 24‐hour blood pressure and heart rate, pulse pressure, pulse wave velocity and carotid intima‐media thickness were evaluated. Compared with placebo, liraglutide increased 24‐hour heart rate by 4.6 beats per minute (BPM); P = .0015, daytime heart rate by 3.7; P = .0240 and night‐time heart rate by 7.5 BPM; P < .001 after 24 weeks. Diastolic nocturnal blood pressure increased by 4 mm Hg; P = .0362 in the liraglutide group compared with placebo. In conclusion, in patients with long‐standing type 1 diabetes, liraglutide as add‐on to insulin increased heart rate and did not improve other cardiovascular risk factors after 24 weeks of treatment.     

Impact of body mass index on postoperative complications and long‐term survival in patients with esophageal squamous cell cancer

Undernutrition and cachexia have been suggested to be risk factors for postoperative complications and survival in cancer patients. The aim of this study was to investigate whether body mass index (BMI) is related to the short‐term and long‐term outcomes in patients who undergo an esophagectomy for the resection of esophageal squamous cell cancer (ESCC). Three hundred forty patients who underwent an esophagectomy for the resection of ESCC between 2003 and 2008 were retrospectively reviewed. The patients were divided into two groups: an L‐BMI group characterized by a BMI < 18.5 kg/m² and an N‐BMI group characterized by a BMI ≥ 18.5 kg/m². Clinical and pathological outcome were compared between groups. The study included 40 patients in the L‐BMI group and 300 patients in the N‐BMI group. A clinicopathological assessment showed that nodal involvement was seen more frequently in the L‐BMI group (P = 0.016). Pulmonary complications seemed to occur more frequently in the L‐BMI group (P = 0.006). The 5‐year overall survival rate was higher in the N‐BMI group (63.6%) than in the L‐BMI group (32.3%) (P < 0.001). The 5‐year disease‐free survival rate was also higher in the N‐BMI group (58.0%) than in the L‐BMI group (33.6%) (P = 0.001). In multivariate analysis, the BMI (hazard ratio, 2.154; 95% CI, 1.349–3.440, P = 0.001) was found to be an independent prognostic factor for overall survival. Our data suggested that a lower BMI not only increased pulmonary complications but also impaired overall and disease‐free survival after an esophagectomy for the resection of ESCC.     

Variation of health‐care resource utilization according to GERD‐associated complications

Complications associated with gastroesophageal reflux disease (GERD) can include esophageal stricture, Barrett's esophagus, gastrointestinal hemorrhage, and extraesophageal symptoms. The impact of GERD‐associated complications on health‐care utilization deserves further evaluation. We identified commercial enrollees 18–75 years old with claims for GERD (International Classification of Diseases, Ninth Revision, Clinical Modification Codes: 530.81 or 530.11) and subsequent usage of proton pump inhibitors from 01/01/05 to 06/30/09. The initial GERD diagnosis date was designated as the index date, and patients were studied for 6 months preindex and postindex. Eligible patients were subsequently stratified based on medical claims for GERD‐associated complications as follows: stage A (GERD diagnosis, no other symptoms), stage B (GERD + extraesophageal symptoms), stage C (GERD + Barrett's esophagus), stage D (GERD + esophageal stricture), and stage E (GERD + iron‐deficiency anemia or acute upper gastrointestinal hemorrhage). Patient characteristics, health‐care utilization, and costs were compared between stage A and each stage with complicated GERD (B–D). Of the 174,597 patients who were eligible for analysis, 74% were classified as stage A, 20% stage B, 1% stage C, 2% stage D, and 3% stage E. Relative to stage A, patients in stages C, D, and E were significantly more likely to visit a gastroenterologist (13% vs. 68%, 71%, and 38%, respectively) and had higher rates of esophageal ulcers (0.3% vs. 8%, 5%, and 3%, respectively) and Nissen fundoplication (0.05% vs. 0.6%, 0.3%, and 0.2%, respectively). Six‐month GERD‐related costs ranged from $615/patient (stage A) to $1714/patient (stage D); all‐cause costs ranged from $4195/patient (stage A) to $11,340/patient (stage E). Compared with stage A, all other cohorts had significantly higher all‐cause and GERD‐related costs (P < 0.0001 for all comparisons). While patients with more severe GERD represented a relatively small portion of the GERD cohort, they demonstrated significantly greater health‐care costs and overall utilization than patients with uncomplicated GERD.     

Diabetes mellitus is an independent risk for gastroesophageal reflux disease among urban African Americans

An association between gastroesophageal reflux disease (GERD) and diabetes mellitus (DM) has been reported. Studies have not been population‐based and have failed to include a representative sample of African American subjects. The aim of the study was to determine if DM is independently associated with GERD among urban African Americans. Single‐center, population‐based survey utilizing a complex, stratified sampling design. To obtain a simple random sample of the entire African American community, targeted survey zones and hand‐delivered invitations were identified. Participating subjects had to be self‐described African American, age ≥18. Surveys were completed at a computer terminal assisted by a research coordinator. Four hundred nineteen subjects (weighted sample size of 21 264 [20 888–23 930]). GERD prevalence was 23.7% (95% confidence interval [CI] 23.2–23.9). GERD prevalence was 41.5 % in those with DM versus 20.6 % for those without (P < 0.001). Those with GERD had DM longer but had lower glycohemoglobin levels. The prevalence of ≥2 DM comorbidities was higher in those with GERD (odds ratio [OR] = 2.06; 95% CI 1.71–2.48). In the final model, age >40, DM, increasing body mass index, harmful drinking, and increasing smoking dependence were independently associated with GERD. For DM, there was significant effect modification by gender. In males, the risk was (OR = 4.63; 95% CI 3.96–5.40), while in females, the risk was markedly attenuated (OR = 1.79; 95% CI 1.61–2.00). Among urban African Americans, there is an independent association between DM and GERD that appears to be stronger in men. More information is needed to understand this association.     

Metabolic syndrome and liver steatosis occur at lower body mass index in US Asian patients with chronic hepatitis B

We have previously shown that ultrasound identifies significant steatosis in patients with chronic HBV (CHB). However, the relationship between CHB, metabolic syndrome (MS) and steatosis is poorly understood. In this tertiary care, single‐centre retrospective cohort study of 617 CHB patients, we examined the prevalence of MS and steatosis in a predominantly Asian US cohort. Patients were predominantly male (57%) with a mean age of 53 years, Asian (88%), on HBV therapy (64%) and had undetectable DNA (65%). 21% had MS, of which hypertension (41%), dyslipidemia (41%) and obesity (32%) were most common. Patients with MS were more likely to be older (60 vs 52 [P < 0.001]), have steatosis (40% vs 17% [P < 0.001]) and have a higher ALT (29 vs 25 [P = 0.003]). Of the 22% of patients with steatosis by ultrasound, a higher prevalence of MS (38% vs 16% [P < 0.001]) and higher ALT (31 vs 24 [P < 0.001]) was observed. Asian patients had a lower BMI than non‐Asians (mean 24 vs 26 [P = 0.001]) but similar prevalence of MS risk factors and steatosis. Asian patients with a BMI between 25 and 30 and two other MS risk factors had steatosis at the same rate as patients with a BMI > 30 and at least two other MS risk factors. We found a strong association between MS, steatosis and elevated ALT in HBV patients. Asian HBV patients have lower BMI than non‐Asians yet have the same prevalence of steatosis and other MS risk factors, supporting guidelines for lower BMI targets in Asians.     

Patients with high body mass index tend to have lower stage of esophageal carcinoma at diagnosis

High body mass index (H‐BMI; ≥25 kg/m²) is common in US adults. In a small cohort of esophageal cancer (EC) patients treated with surgery, H‐BMI and diagnosis of early stage EC appeared associated. We evaluated a much larger cohort of EC patients. From a prospectively maintained database, we analyzed 925 EC patients who had surgery with or without adjunctive therapy. Various statistical methods were used. Among 925 patients, 69% had H‐BMI, and 31% had normal body mass index (<25 kg/m²; N‐BMI). H‐BMI was associated with men (P < 0.001), Caucasians (P = 0.064; trend), lower esophageal localization (P < 0.001), adenocarcinoma histology (P < 0.001), low baseline cT‐stage (P = 0.003), low baseline overall clinical stage (P = 0.003), coronary artery disease (P = 0.036), and diabetes (P < 0.001). N‐BMI was associated with weight loss (P < 0.001), alcohol abuse (P = 0.056; trend), ever/current smoking (P = 0.014), and baseline cN+ (P = 0.018). H‐BMI patients with cT1 tumors (n = 110) had significantly higher rates of gastresophageal reflux disease symptoms (P < 0.001), gastresophageal reflux disease history (P < 0.001), and Barrett's esophagus history (P < 0.001) compared with H‐BMI patients with cT2 tumors (n = 114). Median survival of N‐BMI patients was 36.66 months compared with 53.20 months for H‐BMI patients (P = 0.005). In multivariate analysis, older age (P < 0.001), squamous histology (P = 0.002), smoking (P = 0.040), weight loss (P = 0.002), high baseline stage (P < 0.001), high number of ypN+ (P = 0.005), high surgical stage (P < 0.001), and American Society of Anesthesia scores, three out of four (P < 0.001) were independent prognosticators for poor overall survival. We were able to perform propensity‐based analysis of surgical complications between H‐BMI and N‐BMI patients. A comparison of fully matched 376 patients (188 with H‐BMI and 188 with N‐BMI) found no significant differences in the rate of complications between the two groups. This larger data set confirms that a fraction of H‐BMI patients with antecedent history is diagnosed with early baseline EC. Upon validation of our data in an independent cohort, refinements in surveillance of symptomatic H‐BMI patients are warranted and could be implemented. Our data also suggest that H‐BMI patients do not experience higher rate of surgical complications compared with N‐BMI patients.